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The importance of communication in the practice teacher-student health visitor relationship

When a troubling incident with a student occurred, one teacher took a step back to reflect on her own practices – and made important realisations and changes as a result. Katie Kirk and Clare Hopkinson explain.

Katie Kirk, health visitor, Gloucestershire Care Services Clare Hopkinson, senior lecturer: adult nursing, Faculty of Applied Science, University of the West of England

Key points:

  • Communication is an essential prerequisite in the teacher-student relationship.
  • Student health visitors with previous clinical experience may have problems in adjusting, owing to fixed habits and patterns.
  • Regular feedback can increase students’ confidence; objective feedback, which conveys warmth and a shared understanding, enhances trust.
  • Reflection can help students recognise, and learn from, their deficits.
  • Timely reflective discussions within a non-judgemental environment foster mutual respect.
  • Students with a confident practice teacher will be well equipped to lead, plan and evaluate care at individual, community and population level. 

Abstract

The teacher-student relationship is a powerful component of the learning environment, with communication an essential prerequisite. For those coming to health visiting with previous clinical experience, this adjustment may be problematic, putting strain on the teacher-student relationship. I have described and analysed a communication incident between a student (a former mental-health nurse) and practice teacher that demonstrates this. Learning to step back and reflect enabled a more effective student-centred learning environment. For best practice – arguably, this is a supportive dialogue immediately after the event – the ideal communication strategy is to encourage a student’s reflection and motivation. Regular feedback within an ongoing therapeutic partnership, including both verbal and non-verbal communication, increased the student’s confidence and self-esteem whereby she learned to recognise her own deficits. Furthermore, the practice teacher gained personal satisfaction. It is important to recognise that some health visitor students require additional support in their transition from experienced clinician to student health visitor where a different skill set and practice is required. Using effective communication strategies is pivotal, not only to the student’s developing competence, but to the teacher’s own understanding of the application of principles, methods and challenges of eliciting competence.

Key phrases: practice teacher, communication, teacher-student relationship, constructive feedback


Introduction

There is limited published literature on the day-to-day role of the practice teacher in supporting student learning in practice, although the importance of communication in education and healthcare settings has been explored in a number of reports and also NHS policy documents (NHS, 2010, DOH, 2012). Malterud (2001) asserts that clinical knowledge consists of interpretive action and also interactive factors that include communication, opinions and experiences. These may not always concur with what Appleton and Cowley (2008) have identified as critical attributes of the core principles of health visiting. Given that adult learners often enter into health visiting with a broad foundation of experience, Al-Wahaibi and Almahrezi (2009) argue that, because of this, they may be less open-minded as they have already acquired fixed habits and patterns. Core 1/Level 3 of the NHS Knowledge and Skills Framework (NHS, 2004) for health visitor competency indicates that the worker ‘recognises and reflects on barriers to effective communication and modifies communication in response’. Clearly, this demonstrates the centrality of communication in the health visitor role and the need for the practice teacher to support learning in relation to communication. This highlights the need to consider models and theories in an attempt to understand the factors that influence the learning environment and communication between student and practice teacher.


Role of the practice teacher

Practice teachers complete an academic course of study at a higher educational institution (HEI) that enables them to be registered with their employers and the HEI as suitably trained to provide clinical practice education for student health visitors (DH, 2012). Practice teachers are responsible for organising and co-ordinating learning activities for students so they can achieve the practical knowledge and skills to register as a specialist community public health nurse. They are also pivotal in the education and clinical placement training of newly qualified colleagues and return-to-practice learners, and are role models to their colleagues (DH, 2012). The practice teacher assesses skills, attitudes and behaviours, provides evidence of the student’s achievements and is ultimately responsible for signing off achievement of proficiency. Practice teachers who sign off students as being proficient in practice are confirming that the student has met the desired NMC standards of proficiency and is capable of safe and effective practice (NMC, 2008).

According to Liberante (2012, p.2), ‘the teacher–student relationship is one of the most powerful elements within the learning environment’. Establishing effective working relationships and facilitation of learning are the first two of eight competency domains that are mandatory requirements for qualified practice teachers (NMC, 2008). Furthermore, the ability to communicate is an essential prerequisite in cultivating an effective student-teacher working relationship (Gopee, 2011). Therefore, this paper critically reflects on the development of a student practice teacher using a specific communication incident between herself and a student health visitor. Through exploration of the incident below, the aim of this paper is to extrapolate effective communication strategies as part of the practice teacher role.


Incident

I undertook a home visit accompanied by a student (a former mental health nurse). It was agreed with the student prior to the visit that she would lead and I would interject only where necessary. The purpose of the visit was to assess the weight of a three-week-old baby (primigravida) who had failed to regain his birth weight at the new birth visit. The mother appeared anxious and exhausted and in need of advice and support. The baby’s weight was excellent but, following a comprehensive and satisfactory breastfeeding assessment, the student’s advice was misleading and failed to reassure the mother. I intervened tactfully yet the student disagreed with me in the presence of the mother. At this stage, I had to explain to the mother that she was a student (which the student should have made clear at the outset) and completed the visit myself. I recall experiencing feelings of discomfort immediately after the visit and, unsure how to manage the situation, I discussed it with a senior colleague who advised that I address the issue with the student at the next opportunity. Subsequently, I identified my concerns with the student about her performance and we agreed an action plan, which included a teaching session to help develop her clinical knowledge, alongside a discussion around the health visitor attributes. The student was receptive and completed the programme to a satisfactory standard. 


Discussion

Adult education (andragogy) supports the notion that humans develop fixed concepts about themselves and their environment (Weiss et al, 2014). Knowles (1980) suggested that, when adults are in situations where they are not allowed to be self-directing, they experience a tension between that situation and their self-concept. This may help to explain the student’s apparent resistance and unwillingness to learn from the situation. Kolb (1984), however, purports that ideas are not fixed but are formed and modified through experiences, which would suggest that the student health visitor’s self-concept could be affected through the relationship with the practice teacher. Indeed, the NMC (2008, p.49) expect the practice teacher to ‘enhance understanding of the optimum way to foster the student’s personal growth and development by use of effective communication and facilitation skills’.

I now try to integrate the four indicators of authenticity suggested by Brookfield (2006): 1) congruence; 2) full disclosure; 3) responsiveness; and 4) personhood, into my practice with a student. Congruence refers to consistency between the teacher’s words and actions. In the incident above, I failed to address the issue in order to avoid conflict, thereby mitigating the effectiveness of congruence. As I began to adopt this attitude, I found it easier to understand how my anxiety blocked my ability to communicate non-judgmentally, and have learned the value of responding through empathetic understanding to what I previously perceived as an ‘attack’. I have incorporated learning objectives and student expectations and, where necessary, raised uncomfortable viewpoints, thereby making full disclosure of my intentions in advance as advised by Brookfield (2006).    

Descriptive messaging can be an effective alternative to judgmental and prescriptive feedback. The components of the descriptive messaging include behaviours + feelings + interpretation (Ostermann and Kottcamp, 2004). In the incident given, this technique was used by me to describe the student’s observed behaviour on the home visit, followed by how the situation made me feel. I emphasised my feelings of concern for the mother’s perception of our roles as well as the apparent conflicting advice she received. By explaining these feelings, I was able to facilitate the final stage of helping the student understand why I felt as I did. Consequently, I was explicit in my explanation of why I felt tense by explaining the potential consequences of the student’s actions. Implementing this technique avoided conflict and led to a shared understanding and respect of each other’s learning journey.

Descriptive messaging requires a degree of self-awareness – as Farber (2006) suggested, full disclosure and self-awareness are inextricably connected. Moreover, Kondrat (1999, p.452) proposed that self-awareness encompasses ‘becoming awake to present realities, noticing one’s surroundings, and being able to name one’s perceptions, feelings, and nuances of behaviour’. Consequently, I have learned that, as an adult learner, the student’s established ideas that are redundant in her new role may be challenged, and this is true for me, too.

I have learned to step back, and reflect on my listening and observation behaviours, and this has enabled me to develop a learning environment that is student-centred. By critically reflecting on the incident with my own qualified practice teacher, I was able to explore the tensions arising from the incident. I then felt a greater sense of commitment to both the student’s and my own learning. Critically reflecting on the student’s response, and my feelings about how to manage this positively, has taught me to follow the student’s thought processes, which has encouraged a more effective empathic response as soon as possible after the event (McKimm, 2009). This is central to developing learners’ competence at all stages and needs to be an accepted part of the overall communication and facilitation process (London Deanery, 2012).

Previously, I used the sandwich model of feedback (Von Bergen et al., 2014) where students’ strengths are acknowledged first in order to avoid defensiveness. Von Bergen et al (2014) propose that, because the positive comment is a precursor to criticism (an unintended consequence), reinforcement is less credible. Credibility is essential for feedback to be perceived as meaningful (Watling et al, 2012), and this is particularly important in healthcare where there may be tensions around professional boundaries and status (McKimm, 2009). The experience above has taught me that feedback is complex, yet most effective when given as a supportive dialogue that facilitates the student’s self-knowledge and awareness. Therefore, I now focus on the essential goals of feedback, encouraging learners to reflect as a motivation for performance improvement (Cantillon and Sargeant, 2008). This involves conversations with the student based upon a developmental dialogue, which can be incorporated routinely into the learning environment. Regular feedback in this way appeared to increase the student’s confidence and self-esteem, as well as giving me a sense of personal satisfaction.

Cantillon and Sargeant (2008) emphasise the value of students’ own ability to recognise their deficits through sharing concerns about their performance and what they would have liked to have done better. Feedback frameworks require specific communication techniques to maximise learning opportunities and positive outcomes, but teachers should be particularly careful with wording when giving feedback, as language implications of using descriptions such as ‘weak’ or ‘poor’ can cause irretrievable breakdowns in communication and relationships (Race, 2004). Ramani and Krackov (2012) also suggest using descriptive and neutral wording when delivering reinforcing or corrective feedback. This means describing the behaviour that needs to be changed in an objective, non-judgmental way based upon the specific observation of the incident, rather than the student’s personality. Whilst this can be challenging for the practice teacher, it represents a means of helping the learner focus on features of their performance that need to be addressed and is less likely to be perceived as a personal attack (Cantillon and Sargeant, 2008). Using this strategy has successfully led the process of feedback, raising the student’s awareness and understanding of issues, empowering her to take action to improve her clinical practice.

I also reflected on my own handling of the situation, using John’s model of reflection (1995), which proposes the consideration and consequences of these interactions. Five cue questions are used, enabling a breakdown of experience and reflection of the process and outcome:

  1. Description of the experience (including what were the significant factors)
  2. Reflection: what was I trying to achieve and what were the consequences?
  3. Influencing factors: what factors, such as external/internal factors and knowledge, affected my decision making?
  4. Could I have dealt with it better? Did I have other choices and, if so, what consequences would they have had?
  5. Learning: what is likely to change as a result of this experience and how did I feel about it?

Both teacher and student participate equally and should be partners in the process of feedback (Ramani and Krackov, 2012). This can be facilitated by both non-verbal (implicit) and verbal (explicit) behaviours, which convey warmth and availability (Mehrabian, 1981). I used verbal immediacy in interactions with the student in a variety of ways including Sanders and Wiseman’s (1990) idea of employing inclusive words such as ‘we’ instead of ‘you’ and ‘me’, probability (‘will’ vs ‘may’), ownership statements (‘my’ vs ‘our’). Mehrabian (1981) has claimed that non-verbal cues convey up to 93% of a message’s meaning. Therefore, it can be argued that it is the non-verbal behaviours that dominate when there is conflict between the verbal and non-verbal communication. I have shared this with my student to support the development of her own communication skills in practice – a vital component of working with ‘hard to reach’ families, in particular. Sharing a conscious awareness of the impact of non-verbal behaviours has also surprisingly resulted in more trust and rapport with the student.


Conclusions

My development as a practice teacher has highlighted the complex and multi-dimensional process of ensuring that the student-centred learning environment is based upon an open student-teacher relationship. Embedded in this concept is critical reflective practice, which I have used to analyse my communication, assumptions and ways of supporting a student health visitor in the transfer of domain-specific skills and knowledge into her new health visiting role. Since this incident, attention to the nuances of communication has framed the way in which I am now able to be flexible in managing difficult situations by giving me new communication strategies.   In my pursuit of knowledge to enhance my abilities in establishing effective working relationships and facilitation of learning, I have learned that emphasis on interpersonal values influences the development of inter-professional learning and working. The incident allowed me to understand that fostering professional growth and development involves empathy, tolerance, responsiveness and courage, and that the balance of cognition and emotion fosters transformative learning. The incident has highlighted that students may require additional support in the transition of moving from clinical nursing into health visiting, where different skills or practice are required. Identification of these needs through effective communication strategies is pivotal, not only to the student’s developing competence, but to the practice teacher’s understanding of the application of principles, methods and challenges of eliciting competence.


References

Al-Wahaibi A., Almahrezi A. (2009) An application of educational theories and principles of teaching and learning communication skills for general practitioners in Oman. Oman Medical Journal 24(2): 119-27.

Brookfield S. (2006) The skillful teacher: on trust, technique and responsiveness in the classroom. Jossey-Bass: San Francisco.

Cantillon P, Sargeant J. (2008) Giving feedback in clinical settings. British Medical Journal 337: a1961.

Knowles MS. (1980) The modern practice of adult education: from pedagogy to andragogy (revised and updated). Cambridge Adult Education: Englewood Cliffs.

Kolb D. (1984) Experiential learning: experience as the source of learning and development. Prentice Hall: Englewood Cliffs.

Liberante L. (2012) The importance of teacher-student relationships, as explored through the lens of the NSW Quality Teaching Model. Journal of Student Engagement: Education Matters 2(1): 2-9.

Mehrabian A. (1981) Silent messages: implicit communication of emotions and attitudes (second edition). Wadsworth: Belmont.

McKimm J. (2009) Giving effective feedback. British Journal of Hospital Medicine 70(3): 158-61.

NMC. (2008) Standards to support learning and assessment in practice. See: nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-to-support-learning-assessment.pdf (accessed 24 July 2017).

Osterman K, Kottkamp R. (2004) Reflective practice for educators (second edition). First Skyhorse: Thousand Oaks.

Race P. (2001) Using feedback to help students learn. See: heacademy.ac.uk/resource/using-feedback-help-students-learn (accessed 24 July 2017).

Ramani S, Krackov S. (2012) Twelve tips for giving feedback effectively in the clinical environment. Medical Teacher 34(10): 787-91.

Sanders J, Wiseman R. (1990) The effects of verbal and nonverbal teacher immediacy on perceived cognitive, affective, and behavioural learning in the multicultural classroom. Communication Education 39(4): 341-53.  

von Bergen C, Bressler M, Campbell C. (2014) The sandwich feedback method: not very tasty. Journal of Behavioral Studies in Business 7: 1-13.

Watling C, Driessen E, van der Vleuten C, Lingard L. (2012) Learning from clinical work: the roles of learning cues and credibility judgements. Medical Education 46(2): 192-200.

Weiss D, Tilin F, Morgan M. (2014) The interprofessional healthcare team: leadership and development. Jones & Bartlett Learning: Burlington.


Why is this topic important?

Establishing and maintaining effective professional relationships is an essential prerequisite in ensuring students achieve the standards set by the NMC. This paper focuses on a high quality, positive learning environment, in which the practice teacher is fundamental in fostering students’ personal growth and development. Critical reflection on communication within the learning environment supports the practice teacher in eliciting student competence, thereby equipping them with the knowledge and skills to enable them to lead and influence others.

What does this study attempt to show?

One of its aims is to show strategies for managing conflict and tension within the student and practice teacher relationship. It acknowledges the difficulties of teaching adult experienced learners and offers a theoretical framework for supporting the practice teacher in her role in leading the next generation of health visitors.

What are the key findings?

Timely reflective discussions within a non-judgmental environment fosters trust and mutual respect. Critical reflection should be a shared experience and embedded within the learning process. Objective feedback, which conveys warmth and a shared understanding, enhances trust.

How is patient care impacted?

Students who have a confident practice teacher as a role model will be equipped to lead, plan and evaluate care at individual, community and population level.

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